In today’s complex healthcare landscape, good design goes far beyond aesthetics as it’s fundamentally tied to safety, efficiency, and patient trust. Usability has evolved from its roots in human factors to become a vital component of modern, data-driven healthcare design. Poor UX can have serious consequences, from confusing patient portals to inefficient clinic workflows. By prioritizing user research, clear communication, and intentional design, healthcare professionals can create systems that not only work better but also improve experiences and outcomes for both patients and providers.
On today’s episode of In Network's Designing for Health podcast, Nordic Chief Medical Officer Craig Joseph, MD, talks with Randolph Bias, Founder and CUO at UXonSpec. We discuss his insights on the evolution of the field, the rise of design thinking, and why intuition alone falls short. We also discuss the critical role of user research and data in shaping effective design, and why investing in usability is essential for long-term success.
Listen here:
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Want to learn more from Dr. Joseph? Order a copy of his book, Designing for Health.
Show Notes:
[00:00] Intros
[00:17] Academic and professional background
[04:00] The evolution of human factors
[07:20] Data versus intuition
[09:15] Selling usability
[15:20] Watching versus asking
[18:30] UX as a profession
[21:22] The cost of poor UX in healthcare
[29:14] Randolph’s favorite well-designed thing
[30:42] Outros
Transcript:
Dr. Craig Joseph: Welcome to the show, Dr. Bias. Where do we find you today?
Dr. Randolph Bias: Dr. Joseph, thank you so much for having me. I'm in my home office in Austin, Texas, where it's a balmy 75 degrees, and a little light rain. Happy to be here. Thank you so much.
Dr. Craig Joseph: I am excited to have you here. I always like to get the origin story for our guests, so let's just start all the way back to where you were born. No, no, no, we won't go that far back. But I think we can go back to you being a college student at Florida State.
Dr. Randolph Bias: We'll start maybe in the last day of junior year. I was a psychology major. I was getting kind of bored with college, didn't really know what I was going to do with a psychology degree. And the day before I went home for summer vacation, I learned that you could get in the honors program with a 3.2 grade point average, which I had instead of what I originally thought was a 3.5, which I did not have. My golf game was in pretty good shape back then, partially explaining that anyway, learning that I could get in the honors program, I thought, oh, okay, well, I'll do some research.
Senior year, that'd be something fun. And so, I had this one professor whom I loved, whom I had taken multiple classes from, and I filled out the application. I went to his office, and he was gone. So, I forged his name and submitted the application. And then the next day, I called him, and he said, yeah, yeah, that's fine.
And so, I got to do some psycholinguistics research as a senior. Then somewhere in there I figured, well, I guess I'm going to have to go to graduate school. So, the University of Texas at Austin was the best grad school I went to. So, Cheryl Bias and I moved to Austin, Texas, never having been west of Pensacola, Florida. And I got a PhD here in cognitive psychology, studying things like things like human perception, cognition, psycholinguistics, and memory.
Dr. Craig Joseph: So, you move from Florida to Texas, and you get a PhD. And then what I like, what was your goal in getting a PhD?
Dr. Randolph Bias: More than anything in the world, I wanted to be an assistant professor, teaching psychology somewhere, making $12,000 a year, and I failed either because I wasn't smart enough, or the market was bad, or some combination of that.
And all my buddies started getting these high-powered jobs at Bell Labs and IBM, and one of them got me an interview at Bell Labs in New Jersey. And so, they were selling themselves as, reasonably enough, human factor psychologists. And so, I got hired a lot for more than $12,000 a year to go be a human factor professional at Bell Labs in New Jersey. We did that for three years and love Bell Labs. Didn't much like New Jersey. And so, three years later, I got hired by IBM Austin to come back here, for which I've been eternally grateful and spent, I think, like 12 years there.
And then a business partner and I started Austin Usability in about 2000th, a small usability lab and consultancy. Oh, there was another company in there, BMC software, which I should have mentioned earlier. I was the first UX guy they hired, and I managed and built that small team in a lab. Then this business partner and I started Austin Usability, a small usability lab and consultancy. And so that covers 20 years of me as a practitioner, human factors, usability, UX practitioner and manager then, and I think 2003 that I finally and all along I'd been publishing a little bit, I still had this vision that maybe I'd become an academic someday. So by the time I got to apply for this job in 2003, this academic job, go to academia at age 50. My resume looked better than the average 20-year practitioner, and so I got hired and then spent 20 years in academia teaching grad students at the School of Information at the University of Texas. Whew.
Dr. Craig Joseph: That's a lot.
Dr. Randolph Bias: Yeah, that was me. Quick version.
Dr. Craig Joseph: That is a lot. All right, let me unpack some of that. So, I am fascinated by Bell Labs. It is in New Jersey. And we can't deny that. But, you know, it's kind of a storied place of a lot of people who just got paid to tinker and think and often with no expectation that they would produce something valuable to a company or humanity. But they did. So, what did they hire? What were you supposed to be doing at Bell Labs? What were you doing?
Dr. Randolph Bias: All disclosure was not at the think tank. I was in a, on a dev side where we were developing software for the Baby Bells, you know, Southwestern Bell. And it was big mainframe stuff. And I was doing usability, human factors stuff, but it was at a different level than now. It was. We made little incremental changes. Here's another thing I'll tell you about Bell Labs. And this is semi-rude. But let me do it.
Dr. Craig Joseph: Oh, I like that.
Dr. Randolph Bias: The smartest people at Bell Labs and the smartest people at IBM are all just the smart, the dumbest. People at Bell Labs are a lot smarter than the dumbest people at IBM. So, the whole time I was at Bell Labs, I kind of at, a, I was kind of new to my practice to industry, but b, I felt like I was dancing as fast as I could to keep up. By the time I got to IBM, I had my feet under my feet. Maybe, and was a little more confident and period. But we'll talk about the transition to usability later.
Dr. Craig Joseph: Okay. All right. So that's fair. So, what were some of the things so similar at IBM where you were kind of working on making software more accessible to humans?
Dr. Randolph Bias: Yes. But there okay. So, this is exactly where I am headed. I think it was probably the advent of the PC whereby human factors kind of segue. Now in the usability where we're worried, I mean, human factor certainly is worried about human cognition, but now we're worried about every man, every woman, every person interacting with a computer. And so now all of a sudden, human factors become HCI, human computer interaction, usability. We're testing individuals. It's everybody who's interacting with computers. And so now all of a sudden usability is broader. Let me say it.
Dr. Craig Joseph: That does make sense. So, it seems like IBM again, the PCs back in the day, you're more focused on making their equipment, their software, more usable by the people who are typically using it, which is not the general population.
Dr. Randolph Bias: Before I showed up, but just as I showed up with what was there, the advent of the PC. And so now we are worried about studying everybody and figuring out who the target audience is. And the target audience is much more diverse for any software product. It was all software.
Dr. Craig Joseph: So, you kind of mentioned quickly this idea that what started off as human factors, and then changed to usability or user experience or design thinking, all of these thing's kind of merge. They get put together in ways that they seem to be. They're similar, but they're not the same. Yeah. Is there, is there one term that's going to be ten years from now? We'll look back and go like, well, now we just call it X.
Dr. Randolph Bias: So, here's the way I understand history. So, at first it was human factors. It can be sneered at by calling it knobology like knobs and dials. They still needed, of course, the early human factors professionals who were worried about fighter planes in World War Two; they still had to certainly understand human perception and cognition. But it was more of a hardware issue then as we, as we talked about, segue into more PC, this PC world where we have, we can't spend a lot of time training people usually. So, we have to have richer usability on any product. Now it's called usability. Human computer interaction, user centered design was in there somewhere.
Now UX is user experience, is the popular phrase that I think that's a reasonable adaptive evolution. For me, design thinking kind of makes my teeth hurt. It just makes me wonder what kind of thinking we are doing before design thinking. And it just feels to me like, you know, I could probably get paid more as the third design thinking consultant than I could as the 2000 UX consultant. And so, it feels contrived or something. There's probably some nuance in there that I'm just not getting that some design thinking specialists would tell you. But that's up to you to find him, or her, them.
Dr. Craig Joseph: So, let's pivot a little bit to data versus gut instinct. So, you have a PhD, so you're smart. I love the gut instinct idea of hey man, like that should be red because that draws your attention. And that's the way it should be. And it works for me. You know, when I'm in charge, which is rare, I get to make it read. But from a data perspective, maybe that's wrong. Maybe that's just me that wants to see it read. And that has the opposite effect. Where do we go from or when did we go from kind of a gut instinct of what user design is, to, hey, we've got data. I mean, has that been your career or has that changed more recently?
Dr. Randolph Bias: It's been my career to convince people not to depend solely on their gut instinct now. So, there are some really intuitive designers. I'm not one. You may be one. There are some that are really good at this. It is just, in my experience, exceedingly rare that you get it right the first time. And relatedly, you are likely not representative of your target audience. So, if you've been working on this product for a year or a month or one day, you are no longer representative of the people that are going to stumble upon, by your product. And so, it's unlikely that your intuition is going to work. And so that's why I've spent a lifetime trying to convince the world of the value of empirical user experience. Research is, like research in advance, to inform the design and then at the end to validate the design before we ship or go live, and then we ship or go live with confidence that, yeah, I would have rather been red, but oh, guess what? People think red means error. So, you know, that really works better if it's purple or your second favorite color.
Dr. Craig Joseph: That's an excellent point and it's something that I've run into before. I always like to throw the chief of cardiology under the bus because I've seen it multiple times where, you know, we did. Yeah, we did user testing. We asked the chief of cardiology and that's what they said, and that's what we went with. Yet that wasn't your target user, because the chief of cardiology has an army of people around him who do all this stuff.
Dr. Randolph Bias: What used to be the case was that the software VP, development VP would read an article, an in-flight magazine about usability and this he or she they would come in to us and say, hey, we're going to ship in two weeks. Can you do usability? Can you do a usability? And we were so glad that somebody was talking to us. We scurry around and we run running usability setting. We say, no, no, you can't ship. Look at all these errors. And then they go too late. We have to ship anyway. But we'll fix that in the next release. Yeah, maybe that's me being old grump. The rising tide has raised all ships. The world is getting it. They still haven't totally gotten it. But for the most part, people are realizing that we can't just depend on Craig Joseph's opinion about what color each icon should be before we ship.
Dr. Craig Joseph: So, you wrote a book. We haven't talked about your book's cost justifying usability, and it sounds like that's the plea that you're making to these executives that, hey, we'll save your money because you won't have to make it better in the second version. The first version will work if you just give us a little heads up before you ship.
Dr. Randolph Bias: 100%. So, I didn't write a book. I edited a book. I actually co-edited two editions of this book with Deborah Mayhew, Justifying Usability and here's the point. Going into that, the way the world worked was we'd be sitting around the table and the director or the vice president in charge of the product would go around the table. And let's say it was a man just for pronoun use. And he'd say to the development manager, what's it going to take? And the development manager would say these many lines of code, this is many people, this much time. And then the testing manager would say, this is when the machines are going to test this percent defect free. This many people. This would be a person for months. The tech pubs manager would say they're going to be this many online documents, as many hardcopy documents as when it helps this many people, this many people. Person months. And the usability guy would go, well; you ought to make it more usable. Its usability is good. It's in all the magazines.
And then when challenged that VP or director would say, well, how I know when it's usable enough or what if I just take recommendations 1, 6 and 14 or how much will this cost me? The usability guy would kind of slink out of the room mumbling something about type one errors, and, and we were dead in the water. And so, the idea is we can be just as good as that software development manager at projecting how much this is going to cost and what the ROI is going to be. We're going to sell more. The customer support burden is going to be less than that, turnover at the customer site, the customers are going to save time, the turnover, there's going to be less. So, we can make those projections based on historical data also. And so that was just the whole point of those two editions. Of course, my usability is to try to put us on even ground as we stump for the necessarily finite resources.
Dr. Craig Joseph: Let's talk about an example, one that when we were preparing for this podcast, you mentioned, a very excellent experience you had was with OS/2 Extended Edition. It was a product that you were involved with. Do I have that correct?
Dr. Randolph Bias: You have that correct. But I'm not so sure people can figure out when you're being sarcastic.
Dr. Craig Joseph: I wasn't being sarcastic, right? You did not have a good time, but it's going to become clear.
Dr. Randolph Bias: OS two Extended Edition, IBM's product by us to extend edition. So, the developers come to us, we get involved, and they show us the user interface that they developed. And the marketing and salespeople have decided that the target audience are people with sysadmin system administrators and database administrators with two years’ experience. The user interface looked pretty convoluted to us, but we found people like that to come and test them. They to test, they could figure it out pretty well. We made some suggestions. There's no system for 500 miles. Giant failure because we had done we all had done a bad job of anticipating who the target audience was.
Dr. Craig Joseph: But this was one where you kind of had an idea even back then that maybe this wasn't the target audience, but you were you were not enabled to kind of overrule the people who developed the product.
Dr. Randolph Bias: Now you're giving us too much credit there. We just trusted them. We were not involved as we should be today. Early on in identifying, maybe we should have done ethnographic research and see who's carrying out these tasks today, these tasks that our new product is going to help people with. So now we were just sitting there waiting for somebody to hand us something, and that's a bad design process.
Dr. Craig Joseph: Yeah. So, let's dig into that just a little bit. So, talk about ethnography. How do I tell you because I'm creating this product for what the target market is. Sometimes I know that sometimes I'm wrong in this instance, what a usability expert? How do they determine if I'm right about who my target audience is?
Dr. Randolph Bias: The most common mental model of that of our discipline is doing some studies of people. Once we have a product, do you have a prototype or a product before we ship? So does the validation of the design. You can also there's also we should be involved early on doing research to figure out what this design should look like. So, first of all, we could just sit here and think, how is this going to work? And we're going to do a bad job of that, just like we would if we decided on the colors without asking anybody. Or we can ask people how they do their jobs. And, oh, that sounds pretty good. Or better, we could go observe people when they do their job, because guess what? Those two are going to have different results. If I ask you, on your PC, Craig, how do you do X? And you go, well, I do A, and then I do B, and then I do see, well, if I come observe you, you do A, and then you look at that little sticky that's on your screen. And then you do B and then you go ask Devon down the hall what she knows.
Well, we need to know these things. And so going out in the real world and observing people carrying out the tasks that our new product or our new release is designed to help people with is going to give us the richest data, richest info to do to drive our new designs.
Dr. Craig Joseph: Yeah. So, I love that because it's not so much. Tell me what you do. Let me just watch what you do. You might say, "What are you thinking?" And I think some people are better than others at describing their thought processes.
Dr. Randolph Bias: Yes, this is probably why we'll do more than one thing. We'll have; we'll look at multiple people.
Dr. Craig Joseph: I remember reading some article about why some professional athletes who are very who are renowned are horrible coaches and some are great coaches, but the ones who turn out to be horrible coaches are because the advice they give to the people that are coaching is we'll just hit the ball. So how does one become a user experience expert? I know what you did.
Dr. Randolph Bias: Here's the deal. So, I don't want to look like an advanced degree bigot. I am one, I just don't want to look like one. I spent 20 years helping people get advanced degrees, and their employers love them. They do great. Well, my age cohort and I, UX professionals, did a bad job of making UX a true discipline. So, there's no grade upon curriculum. There's no universally accepted certification. So, there are multiple companies that will give you a certification as a UX professional in ten weeks. I think maybe some will do it in one week. I believe in my soul that you do not need an advanced degree. You don't need any degree to be a good, even an excellent UX professional. But it will take a while. You can train somebody to do a decent job of carrying out a usability study with ten subjects. Ten test participants don't ask any leading questions dot dot dot. Okay, you can do that. But ours has a complex skill set that's needed. How do you decide which method to use when? How do you advocate for your data? Once you have the data, how do you, as I say, stand for those resources? You can learn all of that. You can get good at all that without the degree. I'm pretty sure you can’t get good at all that in ten weeks.
Dr. Craig Joseph: So, yet you actually need some training and a tincture of time experience. It sounds like both of those things.
Dr. Randolph Bias: And so now the challenge is for the hiring manager to be able to discern who's going to be a good amount of who's not. So, this person comes in, that person's resume looks pretty good and has a certification from this famous place, this famous company, famous group of consultants, probably pretty good. Well, maybe now everybody can be a designer. The design tools are out there, so anybody can design anything. We need more and more UX professionals. So that's the flip side of that coin. But I wish we were better at taking more seriously the scientific, empirical nature of UX.
Dr. Craig Joseph: You know, even when you come out of school, you still kind of need that experience mentorship.
Dr. Randolph Bias: Absolutely. But then when you get your master's degree, I'm going to have helped you do, maybe get an internship, maybe certainly do a final project, a capstone project, which is, just as good as a as if a consultant had done it, connecting you with a real company who has a real need.
Dr. Craig Joseph: Yeah. Let's start talking about health care. We've talked about design. We haven't talked about health care. You get health care. You're a patient. I get health care. I'm patient. Where are some of the big usability problems you see in health care in the United States? If there are any, maybe there aren't any. I don't know.
Dr. Randolph Bias: Well, for me, I have a lot of eye issues, and I have a lot of different eye doctors. And the one there was one office that I would go to, and the last time I was there, the last time I had to sit on six different chairs in four different rooms. And that was a bad user experience. And so, I found another office whose talent, his technology, was just as good as the other place. But the user experience is 100% better. I go into one room, different people come to me every now and then. I have to go to another room for a little test, but it's 100 times better. So? So here. Poor you. User experience costs them money. No, they may not care, but. But I have no idea how many other people are like me and driving them away.
Dr. Craig Joseph: Are there other areas that you've seen like in terms of a billing or inpatient care or more or more generic outpatient care where you've either you've had a bad experience or, or you've seen someone have something that was so easily correctable, easily fixed that it kind of made you nuts.
Dr. Randolph Bias: Let's start on the good side. Well, it'll be good and bad. So, you know, as we talk, I have a concierge doctor that my family doc, who has been my doc for over 40 years, changed his practice to be a concierge-based practice ten or so years ago. I have to spend some of my wife's money every month to send to him for me to stay as his patient. I love this, and here's the joy of it. It makes a phone call. Okay, so before if I'm calling my doc, the doc doesn't get any money. The office doesn't cost him all their time and energy. They don't want that. But with the concierge doctor, I don't know. Once a quarter or maybe twice a year, I'll get something that's usually imaginary, but I don't know. I'll call. I'll say, May I have a call from the doctor? And that day he'll call me back and I'll say, I got this. And he'll say, you also got that? I go, no, I go, okay, I'm healed. I mean, it took five minutes. I didn't have to drive downtown. It didn't take him any time. That's a fantastic feature, which I guess can still be true under the traditional method, but it's not always because he knows me. He given that I always talk to him instead of some clinic of people that helps. He knows that my, you know, glucose was x three years ago.
Dr. Craig Joseph: The idea of a concierge medicine or direct primary care practice where they don't need to generate income with every interaction is unclear. Not to say that that's evil in and of itself, but that's the way they keep the practice open, right? There's they get they have to have an interaction that gets the money.
Dr. Randolph Bias: Well, let me say I recognize how lucky I am to be able to afford that. Not everybody, not because you still need insurance, you need insurance or the big things. This is extra. So, I recognized that. That I'm lucky.
Dr. Craig Joseph: Have you used any patient portals? You know, don't you? Look at these things and go, oh, man, this is poorly designed.
Dr. Randolph Bias: Yes. Maybe 3 or 4 different doctors. Just yesterday, my I went to physical therapy, and she put some stuff in my portal. For me, the biggest issue is just remembering the damn password. Here's a UX concept. I'm the only one that calls this a novice. New. So, I wasn't just a novice the first time I did it. I'm a novice every time I do it. Here's my best example that how much do you want to donate to United Way this year? Well, is that amount monthly or annually? Why don't you tell me? I don't know, I got to go search for it. So. So anyway, so I just wish the portals, all the portals I've used, seem to be pretty good now. I think on one portal I said something to the doctor, and it appeared in the portal. And I said to him later, hey, whoa, we need to talk about this. I didn't say it exactly that way. And I think perhaps the AI program had made an inference that was wrong. And he may have just said, okay, signed off on it or not, it wasn't that bad. My guess is he really did read it, and it was okay, but it was a little disconcerting.
Dr. Craig Joseph: Yeah, well, you've just opened up a big can of worms. So one was, it sounds like that doctor was using Ambient.
Dr. Randolph Bias: Yeah, I think that's right.
Dr. Craig Joseph: Okay, so there was, there was a machine, recording the interaction hopefully with your blessing. And then it generated a progress note for the physician at least a part of the progress note, and it might have gotten something a little bit wrong.
Dr. Randolph Bias: I bet a lot of money that he did read it, and he thought that was fine. It was fine. And certainly, it's with my permission. And I'm glad he's doing it. And it helped. It saves him.
Dr. Craig Joseph: Time. The second thing that you brought up was this concept of open notes, the idea that you're routinely reading the progress notes, the information that your doctor is writing about you is a design, a design choice. I think it's a great idea but causes a bunch of other things that doctors have to think about. They didn't generally think about before, which is, hey, these patients are reading what I'm writing about them. They always could, always could. But it was a pain. You'd have to go get your medical record and often pay for it and then wait for it. Now right there. So, it's just another interesting wrinkle.
Dr. Randolph Bias: Well, it strikes me as only good. It just adds transparency. It helps somebody my age remember my wife and I try not to always work. We try to go into either doctor's appointments together because two sets eyes or two sets of ears, we do that maybe a third of the time, but we try to do it often because we think it helps. Well, now that portal kind of gives you a chance to hear it again, at least some summary thereof. Confirm or deny or more likely, remember that, oh yeah, I'm supposed to do this exercise or quit eating X.
Dr. Craig Joseph: So, let's talk about the other Dr. Bias, the junior Dr. Bias.
Dr. Randolph Bias: My son is a physician, a family doctor, and works for a company that develops this software to help doctors. It's AI-based and natural language processing-based software that helps docs do their charting and other stuff. I don't even know. I think it's brilliant. I think helps. It helps the docs spend more time doing what they want to be doing, helping the patient. But the danger, as I said earlier, might be the way I get so good that the doctors quit, even reviewing it, saying, okay, yeah.
Dr. Craig Joseph: That's a real concern. I'll always have been and will always it. I think the risk is always non-zero that will happen. That definitely is going to happen. Health care involves humans on both sides, right? Humans giving care, humans receiving care. There's going to be errors. There will be errors. And to your point about the potential misinterpretation of something you said or slightly variable thing, if that's the worst that happens, that's terrific. Right. So, I think it's always just an, it's sort of trying to go and say like we'll have zero errors. Then I think the goal should be to minimize the number of errors and they'll be of minimal importance so that, you know, we're going to be very careful about the important things, and we'll try. But you have to accept the fact that, you know, there's going to be some things where you're right. I didn't review the note as carefully as I could have or, or actually that this is how I interpreted what you said. I want to ask you the question that always ask. It's about design and it's something you might share with us or something or things that are so well designed that they bring you joy whenever you use that. Is there something in your life that fits that bill?
Dr. Randolph Bias: My whole life since I was 39, I've driven used convertibles. That's been a lot, I love being in a convertible and my current two, 12-year-old 11-year-old Audi convertible with one button push. I can put the top down. And it is so fast going up or down, I can do it at a stoplight. And that brings me joy. It truly brings me joy to be able to in April in Austin, Texas, to be able to put my top down because I won't be able to in about a month, it'll be 100 degrees. But that does bring me joy. The usability of the convertible top of my old Audi is great.
Dr. Craig Joseph: How do other cars do it?
Dr. Randolph Bias: Well, you know, there was some where you had to get out and do it manually, and there some the top would go down. But then if you want it covered with some sort of cowling or something, you'd have to get that out of the trunk for that. And also steady improvement.
Dr. Craig Joseph: That is awesome. Yeah, it sounds like it's easy and it's fast. Well, Dr. Randolph Byas, it was terrific speaking with you. I think there's a lot of stories inside that you're not telling us about that I'm going to try and get from you the next time we talk, so that we get the real story. All right. Well, thank you so much. It was really great speaking with you.
Dr. Randolph Bias: Thank you Craig. This was great for me, too. I love thinking about these things. As you can tell, I'm pretty passionate about it. And I'm grateful for people like you and my son who are worried about streamlining health care so that I don't have to sit in six chairs in four rooms every time I go see a doctor.
Dr. Craig Joseph: That is fair. All right. Thanks.
Dr. Randolph Bias: Thank you, sir.
READ THE TRANSCRIPT
Show Notes:
[00:00] Intros
[00:46] What is TEAM
[06:06] The importance of consistent care pathways
[08:41] Data, surgeons, and the patient voice
[22:26] Pre-surgical prep
[23:25] Tech tools for follow-up and recovery
[26:36] Rethinking clinical decision support with AI
[29:25] Turning data into actionable insights
[32:32] Karen’s favorite well-designed thing
[33:52] Outros
Transcript:
Dr. Craig Joseph: Welcome to the podcast, Karen Joswick from Benevolence Health Advisors. How are you today?
Karen Joswick: I'm good, Craig, how are you doing?
Dr. Craig Joseph: I am, as always, excited to talk to people like you. Where do we find you today?
Karen Joswick: East coast, Delaware, the first state.
Dr. Craig Joseph: You and I met when we were, you were trying to educate me on the TEAM program, and I had said to you, I use Teams every day. I can even chat on it. And I told you I didn't need to know anything. And you were. You were like, no, no, no TEAM was with no s.
Karen Joswick: Yeah. We use the word TEAM in all senses of the word. I can't tell you how many times we've approached organizations and said, so how's your team doing? And people go; they're great. What are you talking about?
Dr. Craig Joseph: Why don't you tell us a little bit about yourself? How did you get to become the person that you are now?
Karen Joswick: Let's answer what TEAM is. TEAM is the new mandatory bundle payment program from CMS. It impacts about 25% of the hospitals across the United States, and the hospitals were selected based on their geography. Or CMS has a term called CBSA or core based statistical units. And so, it's kind of a big deal because it's a mandatory model. And there was a little bit of betting going on about what was going to happen in Washington. Was the administration going to keep it, you know, move forward with it. And there were a lot of naysayers that said it's going to get wiped like everybody else, or it's not going to be mandatory. And actually, that's not true.
The administration kept the TEAM model. They came out with some new proposed regulations in the last couple of weeks on it, and it's mandatory. So that means these hospitals have to comply. I went into healthcare wanting to make a difference and a change. Same reason why you probably went into medicine. You want to help people and make a change. And I started my career in it and then was asked because I understood all of this data and analytics and informatics work. Could I help the operational teams implement these programs? And kind of just grew from there. And I think part of it, I had a good amount of my career in the state of Maryland, and Maryland's known for innovative models. And so, I think it kind of was a natural growth in that way.
Dr. Craig Joseph: Fee for service versus value-based care. Fee for service, as I understand it is, hey, you do this thing, you get paid. Whether it turns out well, whether the patient really needed it, none of that really matters. You're going to get paid this amount of money with value-based care. It's more like the payer. In this case, the federal government is interested in results and paying for results.
And so, we've had value-based care for decades. That concept kind of started with the HMOs a gazillion years ago, I believe, and it's kind of been some fits and starts, and it's kind of going back and forth. So, this is, yet another, another attempt from the biggest payer in the United States for health care, the federal government, to make sure they're getting their money's worth. And as you mentioned, TEAM is not optional for the 25% of hospitals that were selected by the government. And they, I presume, know who they are at this point.
Karen Joswick: Gosh, I hope you do know who you are. I mean, there's a list out there. I will say, as of a couple of weeks ago, we've done some outreach, and I think most hospitals know. But early on, when the list was out there, there were some that were a little surprised, like, oh, we're on the list.
Dr. Craig Joseph: So hopefully people know, you know, if they're on the list and what do they need to do? So how is this different from other kinds of, value-based care who's being evaluated and what kind of information do they need to present and that kind of stuff.
Karen Joswick: Well, so first, if you don't know, check the list. So happy to send the list and where you find it. But one check the list, and two, if you're on the list, make sure you identify who your point of contact is going to be with CMS. They want to know who they should send emails and data files. There's going to be a whole bunch of information that's going to come straight from CMS to your organization. More importantly, it's going to be a reflection point for an organization to understand the volume of these surgical procedures and understand the key service lines.
So, in prior bundle payment programs, they were predominately in orthopedic space. This program's a game changer and includes cardiac surgery. Not a surprise, right? Think about what the federal government pays for a lot of open-heart surgeries. Right. So, they put CABG in. There is one example. They also included some spine in some bowel surgeries.
And so, I think this is indicative of where the government's trying to go is to lean into the high-cost procedures or also procedures where there's we know care continuum across whether it's in skilled nursing or home health. And, where we think there's opportunities to bend the cost curve and improve quality. And boy, when you think about seniors and the cost that Medicare is underwriting, cardiac surgery seems like a great place. So, the hips and knees and spines.
Dr. Craig Joseph: And I assume the idea from the government is that if this goes well, it won't be 25% of hospitals. It will be.
Karen Joswick: More. Yeah, yeah. All right. It's going to be more. And if it goes well, by the way, they save money. So, if it goes well, it doesn't mean the hospitals will make more money. There are some hospitals that are in a favorable position based on what we've kind of modeled and projected that some, some hospitals, because they're already a low-cost, high-quality provider, may be positioned well. There are most hospitals who are not, and so this is a haircut. Right. And for some of these health systems, it's not a trim. It's a pretty big haircut a couple million dollars a year. Craig, you know, in this day and age, that's huge. That's not just a rounding error for some of our health system partners. These are big cuts.
Dr. Craig Joseph: Maybe let's just dig in on one example. And so, you had mentioned CABG. You were talking about, bypass graft. So, a heart bypass, which is a major, it's a big operation. So maybe talk us through how it is today and then how will it be tomorrow or early of next year for those quarter of hospitals that are on the list?
Karen Joswick: Sure. Well, CABG is a is a good example to talk about. You know, there are patients who get, emergent CABG and there's not really much you can do about that, right. There are patients who are in the CATH lab. They get balloon pumped and they sent to the O.R. and kind of like, that's just going to run its course. Those are patients that you need a clinical pathway for. You need to be able to make sure you have data and insights, and you've got good partners to manage them across the continuum.
But then there's a cohort of patients which is most patients, right, where it is considered, a scheduled routine procedure. And so those are patients that are known to you as a provider ahead of time. And so there's an expectation that, how are you engaging those patients ahead of time? Have you been educating them on what their plan is after discharge? Right. We know for patients who have had this surgery that they need to be up and moving around, and they need to be exercising. And the patients who are up walking around the nursing unit in the hospital are going to be better walking around at home and going to cardiac rehab.
And so there's kind of these basic tenants that good science, right, good care we know about. But frankly, sometimes we're inconsistent and how we do it. And part of it's the patients not being educated, not being aware, not having the right support system at home. And some of it's that we are inconsistent in our clinical practice at some of our facilities, right, for lots of reasons.
And so the model really is kind of pressure testing and saying you need to be consistent, right. Reduce care variation, but also engage the patient ahead of the surgery and also figure out what your plan is going to be after surgery so that those patients who have a CABG, then maybe go home with home health or with cardiac rehab services and not get transferred to a skilled nursing facility for 20-30 days. Right? So really try and manage the cost of that episode and also improve the care. And we know patients who have a good destination right at home and good support system. They're going to be less likely to end up as a readmission. And I think we all know, like the challenges with readmission, not only around cost but quality. And it becomes a downward spiral.
Dr. Craig Joseph: Is the government looking, how are they going to be evaluating how consistent the care is? How are they going to be evaluating what kind of rehabilitation? That's one of my favorite terms as opposed to rehabilitation, you know, how do they evaluate that? Or is it just no, it's the outcomes. Like we don't really care what you did. If you have, majority of your patients don't bounce back and they're meeting certain criteria afterwards, it doesn't really matter what you did before. It sounds like it's somewhere between those two extremes.
Karen Joswick: Yeah. No, you're exactly right. So I think there is an expectation on your benchmark cost. That's just it, it's a cost program. There's a cost savings program. So are you less expensive than your competitors in your market? And also how do your outcomes fall? So, there's a variety of quality measures that are included in this program. Right. Some of it around patient experience. Some of it's just around like all cause readmissions and all cause morbidity mortality rates. So, there's measures in place to look at, like you said, outcomes. But then there's the biggest stick, or carrot, really is the cost.
Dr. Craig Joseph: You're being evaluated about your cost compared to your competitors compared to like kind of peer institutions in your area. It sounds like.
Karen Joswick: Yeah, your market. And the challenge with these, you know, sassy CMS is word CBSA. So, score based statistical areas I'll use in the word market. In some organizations, their market is small. In other words, it's like California, Oregon, and Washington, right. And so like, they're massive geographies being compared to Sacramento when you're in Oregon may or may not be right. Really fair assessments based on Metropolitan. And we see this in New York, on the East Coast. There's a lot in the New York New Jersey area, etc.
Dr. Craig Joseph: Is this significantly different than two years ago with a different program for a different surgery? Like you'd said earlier, orthopedic surgery tends to be the one that payers in general and the governments specifically look at. But is this much different? It sounds like one of the things that sounds different to me is the fact that I'm going to be judged based on how much I bill versus my other people, either in my region or my state. Is it more of the same or is this a particularly different kind of approach?
Karen Joswick: Yeah. So, yes. So, it's a little bit of the same. It's a bundled program. So we've had bundles for decades and decades in health care. So that part's not new in the fact that we're including orthopedic procedures. There's been a huge shift right over the last 15, 20 years to move routine hips and knees out of the hospital into ambulatory care. Right. Bundle those, that parts not new. What is new is that some of those other specialized procedures, like we talked about cardiac surgery, is a perfect example. And the fact that you're going to be graded, if you will, and compared against your market. So you're not beating against yourself, right.
Comparing against yourself, but you're trying to beat the market, not just improve your own cost. And that's important. For lots of reasons. One, you may not know where you sit compared to your market. Right? So, a lot of health systems don't have good benchmarking information and data about where they sit relative to the hospital down the street. The other thing that I think is a game changer on this one is the service line engagement typically and a fee for service world cardiac surgeries. The last area you touch for lots of obvious reasons. And so, this is one that's going to really challenge health systems to have their foot kind of in both canoes. Right. How do you balance fee for service and value-based care and hope that you don't hurt either side?
Dr. Craig Joseph: One of the things that was initially confusing me, and some listeners might be confused about with respect to needing to know how much I charge for this, my hospital charges for this procedure versus others in general.
I've always taken this simplistic view because I'm a simplistic person, that, hey, I could charge $100,000 or I could charge $1 million for this procedure, for this admission, this hospitalization, I'm going to get paid X number of dollars based on the DRG. And so that was always my kind of assumption. It doesn't really matter what I charge because I can send a bill for anything. I'm just going to get what I'm going to get. But now that's actually or maybe never, but certainly not now that that's not the case. The more I charge, even though I can charge $1 million and I'm going to get $50,000, it's going to not work great if I'm charging $1 million. And if my, others in my area are charging, for the same procedure, DRG half of that, it looks bad and it's going to be calculated as such.
Karen Joswick: Right. And I think the best way to really kind of needle down more on that is the total cost of care. So, for these patients, yes, you can charge for your surgery, but are your patients going to home health, which is, you know, maybe $1,000 of expense versus skilled nursing, which is maybe $25,000 for that post 30-day window? Are your patients having a bunch of extra scanning and imaging and so forth pre procedure that maybe they don't necessarily need is a is it a necessary variation in care based on the standards. So those are kind of the puts and the takes.
And then to your point, yes, there's a whole internal exercise that health systems should be doing around their fixed costs. So what are you charging versus what does it cost you to actually provide those services. And that's really where I think there's a sweet spot. Organizations that are looking at their internal cost structure, how well they're managing their internal costs to provide the care. And then also looking at the care continuum, what are those patients experiencing? Are they going to skilled nursing? Are they going to home health? Are they getting extra physical therapy appointments, imaging etc.?
Dr. Craig Joseph: So now that we all understand what this is, sounds like, step number one is to know if your hospital is in the group or not, which most people probably know by now. But sounds like there's a link that you can go to and see that list.
And then step two, once you know that you're in this list and probably it's not a bad idea for folks who aren't on the list now, given the fact that they might everyone might be on the list soon, is to start collecting some data and some of the data they surely have. Surely there are other programs or other quality metrics that hospitals have to be collecting. One of the new ones is, hey, how much am I charging for this on average? And again, not just for the procedure, but for all the care that's involved versus my competitors. So, they need to get that information. How you get that information, Karen, do you just call up? Hey.
Karen Joswick: It's a yes or no, right. So, if you're on the list and CMS has your contact information, you will eventually get claims data from CMS. But that's not going to be until later this year. So, you're going to need to look at your internal assets and tools. So, you know, depending on whether you're currently in MSSP. So a Medicare shared savings ACO, maybe you already have claims data, maybe you already have a pop health platform or a tool that you're using to do that, that some of the hospitals, for sure, there's many hospitals that frankly, they don't have those tools in play, and they're on the list and they don't have access to the data. And so, then there are certainly partners that have access to benchmarking, where they can give you the analytics to help at least start planning to do that work. And that's some of the work that we're doing to help organizations right now is forecast where they have opportunities to focus on care redesign.
Dr. Craig Joseph: Are there other data points that folks should be collecting that you're seeing that they don't have, that are unique for this program?
Karen Joswick: I'm a firm believer they really should know by those service lines which of those stocks are employed versus a community-based or a partner. I think that there is an opportunity around provider engagement to really be intentional. Certainly with your employee docs, but also with your community docs that you know right now, if you've got, you know, maybe a spine surgeon that's in the community, but they have privileges and they operate, but there's an opportunity to lean in around quality and engagement in this. There should definitely be conversations, right. And an evaluation of who's employed, who's in your community. The same thing is true with your post-acute partners. Who are you sending these patients to? Do you have their data? Do you have a partnership? Do you have a preferred partnership? So there's definitely some internal operational areas that the organizations should be evaluating as they prepare.
Dr. Craig Joseph: Is there anything that differs based on the specialty? So ortho versus cardiac versus GI is pretty much all the same. Or are there any numbers? Oh my. For gastroenterology really need to know X.
Karen Joswick: Cardiac surgery is usually the most expensive, and spine, kind of you know, follows some of the bowel surgeries are pretty expensive because they're usually very medically complex. You know, if I were sitting right there in the hospital today, I would want to look at my outliers. So, any patients in the last 12 to 24 months in your med teams, right? You're made exactly like they'll know that they'll know your outliers for your CABG. They'll be monitoring that, especially if they're involved in other registries like STDs, registries. Any of the quality improvement work that you're doing? I pull all of that and really dig deep, on where you are performing right now.
Dr. Craig Joseph: Okay. And you mentioned engaging with your clinical team, especially the surgeons and procedural, as.
Karen Joswick: I enjoy working with surgeons. And maybe it's because throughout my career I've had the ability to do that. So, you just kind of learn what motivates and engages them. Right? So, these are typically very passionate, quality focused. They truly are outcomes focused. They don't want a bad outcome. Nobody wants a bad outcome. And so I think if you position this program as an opportunity to really evaluate how their patients outcomes are doing and get them the support needed, whether it's special care protocols or figuring out how your care management team can help support them for discharge planning or realization like you talked about.
I see this as a great way to engage those surgeons, maybe in ways that you haven't since maybe the service line launched, or a program opened, or a new surgeon came on. Right? Typically, those movements are when organizations will have a, oh, we should. We just hired a new cardiac surgery specialist. Let's look at our clinical protocols.
Well, you should be doing that more routinely. So, I think this is a great opportunity to have those conversations. And then I'm a big proponent of sharing the data with them, helping them understand where they're sitting and help them be competitive, because by the very nature they're competitive. They want to know; they want to be better than others. And so, I think supporting them in that way is the best way to do it.
Dr. Craig Joseph: Yeah, I love that. From an intentionality perspective, physicians are 100% and surgeons 1,000% are competitive. And, sharing those data points with them, whether they agree that they're important or not, they want to do better than that next person, and especially if they have a negative opinion of that, of someone, they're like, oh, they're beating me at this thing. I don't really, even if I don't see the value, I will not allow them to beat me at this thing. So, yeah. And so, engaging with the surgeons and procedurals makes a ton of sense. We haven't talked about another, important person in this endeavor, which is the patient. Are there things that we should be doing to engage the patient directly, or is this something that now the clinical team and the operations folks are the ones who are the only important keys in this puzzle?
Karen Joswick: I think you know the answer to that one. Right? Patients are at the center of all that we do. It's amazing how many patients don't have a good understanding of what their recovery process could look like for these procedures. It's I mean, even for things that are, that are routine, like, like a knee, some people feel really, you know, you have different experiences. You'll ask a patient or a friend, hey. And they'll say, I had no idea it was going to be so hard to get up the stairs and shower. I had no idea what it was going to be like. So, there's I think there's an obligation, right, to make sure that we are really arming patients and families and their support systems better when they have these procedures.
And I think that's ultimately going to get us into a better place long term around outcomes. But if you haven't invested time and energy resources into educating patients ahead of the surgery, right? Not immersion. Right. But for the routine and scheduled, I just you're just not in a good place long term. And if people have time to focus and plan and worry about the steps to get someone into the house or make sure they have time off those first couple days, you know, as a supporter for their family or their loved one. It makes a big difference. And there's a lot of digital tools too, right, to be checking on your incision site and send us a picture of that. Right. There are so many tools that are out there now that it's kind of like we have to be doing this, in my opinion, for sure.
Dr. Craig Joseph: We need to involve the patients. And I love the idea of kind of doing, again, that pre check of trying to get you in the best shape you can be before the surgery, assuming that it's not urgent. Of course. You know, can it wait a few months for you to quit smoking or for you to start exercising a little bit? Yeah. If so, we know you're going to do better afterwards. And the concept of oh, no one asked you where your bathroom was located because it is upstairs. So that's where the showers are, we're going to have a problem if there's no one there to help you. And that's going to lead potentially to you, not to you kind of failing at home.
And then having to go to a post-acute facility. And then that's going to cost a lot more money. And it's also not as much fun to be in a facility like that as it is to be at home. It's certainly better to be at home. So sometimes these little pieces of work which don't cost a lot can really bring some value. Let's talk about how you kind of teased us a little bit with some digital tools that might be helpful. One of them is using the patient portal or an app that can take a picture that you can use. Take a picture with your phone and send it to your surgeon or your surgical team. And hey, there's really no reason for me to come in the main question that you're going to that you need to see me for is just to look at my wound. If the rest of it is just me talking to you on the phone, or over a video, then that's easy. And then that saves everyone time and money. Are there other things that you've seen kind of be successful in general for patient engagement for some of these, these procedures?
Karen Joswick: I think there's some really interesting ones specifically around I've seen for cardiac surgery and or those reminding the patient of just some of the exercises that they need to be doing. So, you know, like, did you do these exercises kind of post-surgery, you know, for cardiac surgery, it's, you know, making sure that they're doing there is, you know, incentive spirometry and they're coughing. Right. Just some of these basic things like, have you done this? And those are in the early days. We know that makes a big difference for folks that have had, you know, orthopedic procedures. It's obviously watching the, watching all of these surgical sites, but exercising and moving and, you know, did you get up and move around.
And so, I think that there are gentle reminders and app tools, right, that are ingrained into folks' phones that they can either go to the patient or to their supporter. You know, did mom get up today? And I think that we've certainly grown and evolved so much. I mean, we have reminders to my Amazon is going to run out of paper towels, and I get a reminder, hey, Karen, do you want to order more paper towels? Right? As opposed, why can't we do this with some of our surgical is, and I think we're seeing it, but it's not embedded in just this is good care. Then it goes back to that clinical pathway. This is just good care.
Dr. Craig Joseph: Yeah. I, you know, and that good care concept I think really resonates with clinicians especially. We don't really need to talk about TEAM versus another program. It's just oh it doesn't really matter what your insurance is. It doesn't matter how you're paying for this. These are things that we do for all of our patients who are undergoing these procedures.
Karen Joswick: And oh, by the way, come with some of the other commercial insurance companies who are having conversations if they haven't already. They're looking at this to say, well, why would it matter if it's Medicare or a commercial plan? Why wouldn't we want you to save money for our patients, too? So, I think I've heard from some health systems that we're doing work with that their commercial plan has said we'd like to talk about doing bundles and for these patients too. So, I don't think it's that far for health systems to see a knock on the door about this one.
Dr. Craig Joseph: It makes complete sense. And again, that I typically say that, my job when I, when I've been the CMO before with one foot in the I.T world and one foot in the clinical world, is to make it easy to do the right thing, that the hard part is figuring out what the right thing is in this case where we're being told, and I think there's some consensus about what the right thing is, and then we just need to enable it, pivoting off of that, enabling, making it easy to do the right thing. How do we do that? And the tool that most clinicians use all day is the electronic health record.
So, we're kind of like, I know I've just opened up a whole can of worms. Are there clinical decision support tools, or do we really need to rethink how we use clinical decision support for some of this? Have you seen any organizations successfully figure this out?
Karen Joswick: It's interesting. You said clinical decision support and I think probably everyone listening just like, got a chill, right? I mean, think about how we spent the last 20 years implementing these rule-based algorithms. If this then this, right. And these alerts that we have out to folks. And now we're moving towards more AI tools where we're trying to really learn from prior decisions to make more informed and more enabled, you know, decision support. And so, when I think about how clinical decision support can evolve with value-based care, we really need clinical decision support tools that help us manage some of the outliers and the ones that are, if you will, where we have blind spots. And that's not always been the case for CCDs or, you know, the decision support tools at the 80% that fits in the square peg.
Right? We'll tell you to do this. And so, you think about the patients who we'll pick on the cardiac surgery patients, since that's our theme today that we've been talking about. What about the patients who maybe don't have a good support system, or they don't have transportation, or they are not going to be able to get food at home. And we need to worry about meals on the wheel, meals on wheels, or we need to worry about follow up, transportation to home, whatever it may be. I think that's where there is power in some of the new models and some of the new testing that's happening in their EMR around AI, clinical decision support. And I think this is whereas informatics leaders, we've got to lean in and kind of harness that because it's the 20% that we keep missing. That can be a challenge.
Dr. Craig Joseph: Do we definitely focus on the easy part? Why? Because we're humans and that's easier to do that. And so, but your points well taken in that I found if I really, really want to irritate a physician, I should remind them to do something that they were just about to do. Yeah, they really dislike that. That's a big bummer. And so, kind of making sure that clinical decision support helps, whether it's a physician who's seeing the patient, pre-op or in a, in a follow up, appointment or it's more of a kind of a population health perspective.
Are there any tips or obvious things that we should be doing from a population health, from dealing with multiple patients for team or for other programs like it that we don't that you typically see folks aren't doing.
Karen Joswick: You know, I think that there is a tremendous opportunity to kind of keep your head down and lean in on some of the projects that a lot of health systems are already doing. And, right, those are data standardization. Right now, so many health care organizations are receiving claims data, maybe from a payer or from the federal government, and they just don't know what to do with it. You've got to be able to integrate claims and clinical data together. And if you don't have a roadmap and a plan for that, you're going to be behind. You're just going to be behind. It doesn't matter what model it is. So that's something that's really important. If you don't have a way to give performance dashboards right back to your providers, sometimes we would lovingly call them provider scorecards, right? So, if you don't have those things in play, and that they're actually being used. Right. So, it's not enough to have a dashboard, but are they actually being used in a collaborative sense and driving outcomes? You need to look at that because that kind of data is what's ultimately, we, we see the people who are top tier, top performers in these value-based care programs.
It's because they have the data right in front of them. And they are, you know, just moving right along and using those data insights. And then Craig, the last one I would say is it goes back to the claims a little bit. If you don't have a collaborative relationship with your payer, CMS or your commercial payers. And what I mean by that is there's some sort of data sharing. Right? So, think most health systems work with ten or 15 different insurance companies rate payers. And guess how many file formats are sent to them? Exactly. The number of payers is. Like nobody's using a consistent file format. Nobody's using consistent tools or definitions. And so, the onus, unfortunately, is sitting on the health system, and there are some tools that have starting to improve that. But if you don't have a strategy to take all of this external data in, normalize it and then share it with your clinicians and your operators, you're going to be very hard to blindly perform well without those insights.
Dr. Craig Joseph: Let me just jump up. And in that last word you said insights. That's so it's not the data that I'm interested in. It's what I am doing. What am I doing wrong or what am I not doing right that these insights can bring to me so that I can say, you're right. I never asked about stairs, or no one on my team asked about stairs, or they did, and the patient said, yeah, I have stairs. And then that was recorded dutifully in an electronic health record. And then no one did anything with that information, and we were setting ourselves up for failure. So, yeah, that, that that plan to actually take data and move it into insights and then make actions out of those, that's where a lot of people don't design their processes. Well, this was great, Karen. Thank you so much. We always end with the same question, which is that we're talking about design and intentionality. Is there something that you use that's so well designed that you feel joy whenever you interact with it? Anything like that in your life?
Karen Joswick: I've got kids, probably like most folks, and I have to track them all down and they are everywhere. So, I really appreciate some of the calendaring options to just share with them. But also, there's an app called Life 360 where you can track your kids. And so, like the teenage driver that's driving fast and so forth, so I think me, on a personal level, the ability to monitor and know what's going on with my kids in this tech-enabled world and still be close to them is a good place.
Dr. Craig Joseph: It was much more complicated than now to know people they needed to be. And so, I accept your calendar option, and I think there is some joy in that. It's a lack of stress. Right. Where's my kid? He was supposed to have called me. He didn't call me. Let me track his location. He's still on the baseball field or at the high school where I know that he's okay because he's obviously been paying some more attention to sports than to answering my texts.
Karen Joswick: For me, the calendar growing up was the calendar on the wall of the kitchen, and my signal to come home was the streetlights turning on when it was dark. So, it's, it's a very different world to imagine all of parenting and so forth. So, yeah, that's my season of life right now.
Dr. Craig Joseph: I love it; I love it. Well, thank you again. It's been a pleasure. And look forward to seeing how, team works out for the 25%, lucky participants starting next year.
Karen Joswick: Thanks, Craig. A pleasure. It's always great talking to you.